Provider Demographics
NPI:1003860073
Name:MACK, SCOTT WILLIAM (MD)
Entity Type:Individual
Prefix:DR
First Name:SCOTT
Middle Name:WILLIAM
Last Name:MACK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1860 MOWRY AVE
Mailing Address - Street 2:SUITE 400
Mailing Address - City:FREMONT
Mailing Address - State:CA
Mailing Address - Zip Code:94538-1730
Mailing Address - Country:US
Mailing Address - Phone:510-796-7104
Mailing Address - Fax:510-794-9783
Practice Address - Street 1:1860 MOWRY AVE
Practice Address - Street 2:SUITE 400
Practice Address - City:FREMONT
Practice Address - State:CA
Practice Address - Zip Code:94538-1730
Practice Address - Country:US
Practice Address - Phone:510-796-7104
Practice Address - Fax:510-794-9783
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAG077240207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G772401Medicaid
CAC74877Medicare UPIN
CA00G772400Medicare ID - Type Unspecified